New studies reveal that a growing share of outpatient visits are being handled by NPs and PAs, and examine ways to encourage hospital workers to wash their hands more frequently.

An Increasing Number of Hospital Patients Are Seen by Nurses or Physician Assistants without a Doctor

New data from the Centers for Disease Control and Prevention (CDC) reveal a 50 percent increase in hospital outpatient department visits where patients are seen by a Nurse Practitioner (NP) or Physician Assistant (PA), but not by a doctor.

According to the data, in 2000 and 2001, 10 percent of patients were attended by an NP or PA without a doctor. That share increased to 15 percent by 2008 and 2009. In addition, the CDC found that patients at certain types of clinics are more likely to see an NP or PA instead of a doctor: 21 percent of general medicine clinic visits are with NPs or PAs, as are 19 percent of obstetric or gynecology clinic visits. By comparison, just 8 percent of pediatric clinic visits and 5 percent of surgical clinic visits are with NPs or PAs only.

Location is another significant variable, according to the CDC. The more urban the hospital location, the lower the percentage of patient visits that involved only NPs or PAs. More than a third (36 percent) of patient visits to outpatient departments in non-metropolitan areas were handled by NPs or PAs, compared to just 6 percent in large metropolitan areas.

The CDC report reflects the realities of workforce shortages in the health care industry, and comes on the heels of a study released in August finding that NPs achieve similar or superior patient outcomes as do physicians. "Their practice [NPs’ and PAs’] appears complementary and growing over the last few years, especially in areas with few physicians," said Esther Hing, MPH, a statistician with the CDC’s National Center for Health Statistics.

Two new studies examine different approaches to encouraging nurses and other hospital health care workers to wash their hands before treating patients.

A study by Adam Grant, PhD, and David A. Hoffman, PhD, monitored the contents of 66 sanitary-gel dispensers in hospitals before and after posting signs encouraging workers to wash their hands. They found that signs with messages about protecting workers from diseases produced no changes in use of the gel. However, signs that focused on patient health and safety led to significantly increased consumption. “The hand hygiene of health care professionals,” Grant and Hoffman wrote, “increased significantly when they were reminded of the implications for patients but not when they were reminded of the implications for themselves.” The study was published in Psychological Science.

A second study tested how a video-monitoring system affected hand-washing habits. Bruce F. Farber, MD, and colleagues installed $50,000 worth of camera equipment in hospital hallways and patient rooms, focusing on sinks and hand sanitizers. Off-site reviewers used this equipment to see if doctors or nurses washed their hands within ten seconds of entering or when leaving a patient’s room. Researchers compiled data for 16 weeks. Then, in a second phase that lasted 91 weeks, researchers continued monitoring but also posted hand-washing-rate data to electronic boards in the ward’s hallways, so that staff could see how they were doing. They also sent the data to supervisors.

The research team found that in the initial 16-week period—after installation of the video cameras but before the feedback mechanisms were activated—hand-washing rates were lower than 10 percent, even though health care workers knew the cameras were present. Once the feedback began, however, rates shot up, eventually reaching 88 percent over the course of the 91 weeks.